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NPI Code Detail

MEDICARE: MARK R MOELLER PT

MEDICARE: MARK R MOELLER PT
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1225100000XPhysical Therapist3296682401UT

General Provider Information

NPI Number : 1194870592
Entity Type Code : Individual
Provider Name (Legal Business Name) : MARK R MOELLER PT
Provider Business Mailing Address
First Line : PO BOX 682226
Second Line :
City : PARK CITY
State : UT
Zip : 84068-2226
Country : US
Telephone Number : 435-645-9095
Fax Number : 435-645-9092
Provider Business Practice Location Address
First Line : 2015 SIDEWINDER DR
Second Line :
City : PARK CITY
State : UT
Zip : 84060-7323
Country : US
Telephone Number : 435-645-9095
Fax Number : 435-645-9092
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 01/24/2007
Last Update Date : 07/08/2007

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